Religions 2010, 1, 78-85; doi:10.


ISSN 2077-1444 Review

The Duke University Religion Index (DUREL): A Five-Item Measure for Use in Epidemological Studies
Harold G. Koenig 1,* and Arndt Büssing 2


Center for Spirituality, Theology and Health, Duke University Medical Center, Durham, NC 27503, USA Professorship of Quality of Life, Spirituality and Coping, Center of Integrative Medicine, University Witten/Herdecke, Germany; E-Mail:

* Author to whom correspondence should be addressed; E-Mail:; Tel.: +01- 919-681-6633; Fax: +01-888-244-5517. Received: 21 September 2010; in revised form: 16 November 2010 / Accepted: 24 November 2010 / Published: 1 December 2010

Abstract: There is need for a brief measure of religiosity that can be included in epidemiological surveys to examine relationships between religion and health outcomes. The Duke University Religion Index (DUREL) is a five-item measure of religious involvement, and was developed for use in large cross-sectional and longitudinal observational studies. The instrument assesses the three major dimensions of religiosity that were identified during a consensus meeting sponsored by the National Institute on Aging. Those three dimensions are organizational religious activity, non-organizational religious activity, and intrinsic religiosity (or subjective religiosity). The DUREL measures each of these dimensions by a separate “subscale”, and correlations with health outcomes should be analyzed by subscale in separate models. The overall scale has high test-retest reliability (intra-class correlation = 0.91), high internal consistence (Cronbach’s alpha’s = 0.78–0.91), high convergent validity with other measures of religiosity (r’s = 0.71–0.86), and the factor structure of the DUREL has now been demonstrated and confirmed in separate samples by other independent investigative teams. The DUREL has been used in over 100 published studies conducted throughout the world and is available in 10 languages. Keywords: religiosity; index; validity; DUREL

Non-organizational religious activity . (1) How often do you attend church or other religious meetings? (ORA) 1 . as the field is young and research in this area remains somewhat marginal and not well funded. 6 . nonorganizational. Table 1.Tends not to be true. ER: extrinsic religiosity 79 1. 4 . 4 .Definitely not true. was designed to fill this scientific need (Table 1) [3]. such as prayer.Tends to be true. While the research is growing.). I experience the presence of the Divine (i. 5 .Tends not to be true. One factor that may be holding back the study of religion and health is lack of a comprehensive. 3 . 5 . low-burden measure of religiosity that may be easily included in large cross-sectional and longitudinal studies.Never. The Duke University Religion Index (DUREL).Once a week. God) . we documented that nearly 1..200 studies had quantitatively examined some aspect of the religion-health relationship [1]. IR: intrinsic religiosity. 3 . Organizational religious activity (ORA) involves public religious activities such as attending religious services or participating in other group-related religious activity (prayer groups. NORA: non-organizational religious activity.Rarely or never. 4 .A few times a month. 5 .000 additional quantitative studies have been published [2].More than once/week (2) How often do you spend time in private religious activities. meditation or Bible study? (NORA) 1 .Religions 2010. 3 .A few times a year. well-designed and theoretically grounded studies are still relatively rare.A few times a month. In the last 10 years.Tends to be true. Scripture study groups. first published in the American Journal of Psychiatry in 1997.Once a year or less. spirituality and health is expanding rapidly. 2 .Tends to be true. 5 . brief.Definitely true of me (4) My religious beliefs are what really lie behind my whole approach to life .Definitely not true. Items of the Duke University Religion Index (DUREL). In 2001.Definitely not true. 3 . 2 . Aging. 2 . etc. 2 . and intrinsic or subjective religiosity.Once a week.Definitely true of me (5) I try hard to carry my religion over into all other dealings in life .e. Background Research on religion.Two or more times/week.More than once a day The following section contains 3 statements about religious belief or experience. 6 .(IR) 1 . 2 .Unsure. 5 .(IR) 1 . 3 . 1 Abbreviations: ORA: organizational religious activity.Unsure. 4 . 4 . more than 2.Unsure.Daily. and Health: organizational. Please mark the extent to which each statement is true or not true for you.(IR) 1 . nonoffensive.Tends not to be true.Definitely true of me The five-item scale assesses the three major dimensions of religious involvement identified at a National Institute on Aging and the Fetzer Institute conference (16–17 March 1995) on Methodological Approaches to the Study of Religion. (3) In my life.

Three items from the Hoge for the DUREL were then chosen based on their loading on the intrinsic factor. brought into harmony with the religious beliefs and prescriptions. social support. 4. are regarded as of less ultimate significance. This three-item subscale was then added to the single items assessing ORA and NORA to form the final five-item index. 1 80 (NORA) consists of religious activities performed in private. social status.e.. The first two items of the index (ORA and NORA) were taken from large National Institutes of Health supported community and clinical studies conducted in North Carolina (see below).Religions 2010. 8. 10. The final three items were extracted from Dean Hoge's 10-item Intrinsic Religiosity Scale [5] (Table 2)." [4]. or as a congenial social activity). 10-Item Hoge intrinsic religiosity scale. I refuse to let religious considerations influence my everyday affairs (reverse score) Nothing is as important to me as serving God as best as I know how My faith sometimes restricts my actions My religious beliefs are what really lie behind my whole approach to life I try hard to carry my religion over into all my other dealings in life One should seek God's guidance when making every important decision Although I believe in religion. Principal components factor analysis of the 10-item scale revealed two major factors: an intrinsic and extrinsic factor (Table 3) [7]. 1. involves pursuing religion as an ultimate end in itself. My faith involves all of my life In my life. Regression analysis was used to examine the relationship between each item on the scale and depressive symptoms. It is in this sense that he lives his religion. God) Although I am a religious person. I feel there are many more important things in life (reverse score) It does not matter so much what I believe as long as I lead a moral life (reverse score) . a scale which itself was extracted by Hoge from the original 20-item Intrinsic-Extrinsic scale of Allport and Ross and nevertheless holds three items which refer to the ER. severity of medical illness. and relationship with health outcomes (Table 4) [7]. Intrinsic religiosity (IR) assesses degree of personal religious commitment or motivation. Having embraced a creed. and speed of recovery from depression. a form of religiosity mainly “for show” where religiosity is used as a means to some more important end (financial success. 6. I experience the presence of the Divine (i. Table 2. Other needs. functional status. In the Duke Hospital Study. the individual endeavors to internalize it and follow it fully. rather than for religion’s sake alone. 2. and they are. 2. correlation with the total score. comfort. Scripture study. watching religious TV or listening to religious radio. IR. 3. 7. 5. strong as they may be. Development of the DUREL The DUREL is composed of items that capture each of the three dimensions of religiosity described above. so far as possible. the Hoge scale was administered to 455 consecutively admitted medical inpatients [6]. IR has been compared to extrinsic religiosity (ER). in contrast. such as prayer. 9. Allport and Ross defined IR as follows: "Persons with this orientation find their master motive in religion.

07 0.68 0.12 −0.70 0.70 −0. Psychometric Properties The DUREL has an overall score range from 5 to 27.02 0.72 0.15 *** 0.10 Recovery Depression 2 1. the DUREL really consists of three “subscales” (if one accepts the possibility of single item subscales.19 *** 0.26 0.05 0.01 Severity of Med Illness −0.28 0. Item Hoge1 (IR) Hoge2(IR) Hoge3 (ER) Hoge4(IR) Hoge5(IR) Hoge6(IR) Hoge7(IR) Hoge8(IR) Hoge9 (ER) Hoge10 (ER) 1 81 Factor 1 1 Eigenvalues 0.37 0.05 −0.35 1. Each subscale assesses a particular .03 −0.02 0.24 0. and sex controlled) unless otherwise specified.02 0.03 0.15 −0.18 0.18 ** Functional Impairment 0. 2.02 0.16 1.15 ** −0.07 −0.02 −0.07 1.04 0. Associations between 10 Hoge intrinsic religiosity items.19 *** 0.09 0.79 0. 2 Hazard ratio for speed of recovery from depression (using a Cox Proportional Hazards model controlling for family psychiatric history.30 0.04 −0.11 0.02 0.02 −0.61 −0.57 0.36 0.33 0.40 0.17 −0.10 0.05 −0. and sex controlled) unless otherwise specified Table 4. 3 Hoge2 + Hoge6 + Hoge7 (3-item subscale used in DUREL).24 0.25 0.08 0.05 −0.07 0.13 ** 0.52 0.79 0. 90 −0. 1 Standardized betas from regression model (with age.35 0.77 0.05 1.20 0.06 −0.05 −0.01 −0.05 0. and health outcomes. sex.03 −0.07 Major Depression −0.03 −0.72 0.49 0.61 0.74 0. age. Item Hoge1 Hoge2 Hoge3 Hoge4 Hoge5 Hoge6 Hoge7 Hoge8 Hoge9 Hoge10 ORA NORA IR 3 Social Support 1 0.09 −0.04 0.20 1. 1 Table 3.06 0.04 0.05 −0.47 ** 1.09 1.01 0.09 0. religious activities.06 0. since it measures three dimensions of religiosity. 90 −0.16 −0.03 1.53 Pearson Correlation (r) Tota score ORA 0.Religions 2010.02 −0.65 0. Principle components factor analysis of 10-item Hoge scale and item correlations with total score and with ORA and NORA.22 0.31 Standardized betas from regression model (with age.05 −0. race.20 1. race.02 −0.08 0.54 0.12 0.35 0.17 ** p-values: ** p ≤ 0. However.23 0.05 1.24 *** 0.48 0. and severity of medical illness controlled.05 −0.03 Self−Rated Depression −0.25 −0. which is useful at least for our discussion here).68 0.46 0.08 0.20 *** 0. methods described in detail elsewhere [6]).04 0.50 Factor 2 1 Eigenvalues −0.20 1.72 0.65 0.03 0.11 1.01 −0.38 0. *** p ≤ 0.02 0.30 NORA 0.10 −0.01.41 0.09 0.1.05 −0.05 −0.001.16 0.42 0.

8 (1341) 35.0 33.4 20.5 (148) 6.1 (1149) 34. 2. such as prayer. and factor structure of the DUREL have now been demonstrated and confirmed in three separate samples by investigative teams independent from our group [9.71–0. Studies of the DUREL’s psychometric properties by other investigators have also found it to be a reliable and valid measure of religiosity.9 (261) 7. The two-week test-retest reliability of the DUREL is high (intra-class correlation coefficient of 0.6 8.5 11. convergent validity with other established measures of religiosity (r’s = 0. North Carolina).6 (492) 19.4 56.0 32.8 12. Further analysis of the threeitem IR subscale has found that the one item on the subscale best predicts the total IR subscale score (and original 10-item Hoge scale score) (“My religious beliefs are what really lie behind my whole approach to life”).3 (215) 8.4 9.9 (95) Total N 2962 3968 455 (2) How often do you spend time in private religious activities.0 (82) 2. Once a week 28. there are normative data on response rates in both clinical and community populations (Table 5) [11]. Table 5.4 (770) 19.9 8.1 7. or Bible study? 1.2 (857) 35.86).6 17.4 (214) 5. A few time a year 16.2 (42) 2.000 persons aged 18 to 90 participating in the National Institute on Aging’s Established Population for Epidemiologic Studies in the Elderly. In the original Duke Hospital Study (which included consecutively admitted medical inpatients aged 60 or over to Duke Hospital in Durham.3 (394) 14. Never 13.1 18. meditation.0 (92) 3. Population Norms The first two items of the DUREL (ORA and NORA) have been administered to almost 7.Religions 2010.7 10.8 (626) 17.5 (57) 5. it was only moderately correlated with the first single-items of the DUREL.2.8 15. and the National Institute of Mental Health-supported Duke Hospital Study (which included the other three-items of the DUREL as well).9 (290) 9. Two or more times/week 9.7 (336) 8.2 10.1 (718) 15. A few times a month 7.42).5 6.9 46.6 (683) 19. ECA1 EPESE4 DUKE5 ECA2 EPESE3 % (n) % % (n) % % (n) (1) How often do you attend church or other religious meetings? 1.8 4. Daily (or more in EPESE) 39. ORA (r = 0.9 (855) 24.7 (258) 5.7 (415) 10. Reference values (distributions and average scores in North Carolina) for individual items in DUREL.0 (206) 8. and while it was strongly correlated with Hoge’s original 10-item IR scale (r = 0.85). The internal consistency (Cronbach’s alpha between 0.9 13. These are random samples of adults aged 65 or over (NIA EPESE) and of community-dwelling adults all ages (NIMH ECA study). the National Institute of Mental Health’s Epidemiologic Catchment Area survey.40) and NORA (r = 0.91).6 (21) 4.8 (587) 21.1 (37) 3.5 (48) 5. both conducted in central North Carolina. the three-item IR subscale had a Cronbach's alpha of 0. More than once/wk 14.78 and 0. Thus.91) [8].0 18.1 (419) 12.4 (211) . Rarely or never 29.3 (2183) 55.1 5.75.10]. Once a week 8. 1 82 aspect of religious practice or religious devotion.9 19. Once a year or less 7.8 (155) 4.5 (299) 6. A few times a month 19.

Tends to be true 20. Tends to be true 14. in studies of depression or stroke. Tends not to be true 3.8 ( 90) 5. Definitely not true 5.0 ( 18) 2.2) 1 NIMH Epidemiologic Catchment Area survey. 3 NIA Established Populations for Epidemiologic Studies of the Elderly. Definitely true of me 64.6 (1. For example. Definitely true of me 76.3 (1.6 ( 30) 2. Definitely true of me 67. Duke Univ Site. Duke Univ.9 ( 95) 5. 2 NIMH Epidemiologic Catchment Area survey. Site. Tends to be true 19. Duke Univ. while NORA may be positively related to them (since . If all three subscales are included in a single statistical model. Definitely not true 6.1) (5) I try hard to carry my religion over into all other dealings in life 1.Religions 2010.4 (347) Mean (SD) 4.9 ( 27) 2. Unsure 1. N = 455) 83 2. Cont. ORA may be inversely related to both of these disease states.. NC (weighted) (age 18–97). Duke Univ Site.9 ( 36) 3. investigators should examine each subscale score independently in separate regression models when examining their relationships to health outcomes. NC (unweighted) (age ≥ 65). Furthermore. Tends not to be true 5. Instead. NC (unweighted) (age 18–97).2 (292) Mean (SD) 4.3 (306) Mean (SD) 4. Unsure 1. I experience the presence of the Divine (i. Unsure 0.4(1. NC (weighted) (age ≥ 65). Subscale #3 consists of the final three items that assess intrinsic religiosity (IR). `Subscale´ #2 is the second question that asks about frequency of private religious activities (NORA).8 ( 67) 5. combining all three subscales in a single analysis could result in subscale scores canceling out the effects of each other.3 ( 6) 4.0 (175) 4.1 ----12. `Subscale´ #1 is the first question in the DUREL that asks about frequency of attendance at religious services (ORA).1 ( 5) 4.e. multiple collinearity between subscale scores could interfere with accurate estimate of effects for each subscale. Scoring and Analysis The scoring of the DUREL is particularly important both for analysis purposes and for interpretation of results. We do NOT recommend summing all three `subscales´ into a total overall religiosity score. Durham.2 ( 1) 4. 6. Site. God) 1. 5 Duke Hospital Study (unweighted) (hospitalized medically ill persons age ≥ 60. 1 Table 5. Durham.0) (4) My religious beliefs are what really lie behind my whole approach to life 1. Definitely not true 4. More than once a day 6. Tends not to be true 7.7 ( 26) 3. Durham.5 ( 16) 3. 4 NIA Established Populations for Epidemiologic Studies of the Elderly. Durham.3 (56) Total N 2938 3875 455 (3) In my life.3.

Dutch. The DUREL is also not an in depth measure of religiosity. For example. Population Norms The DUREL was designed to measure religiosity in Western religions (e. as well as a host of other health outcomes. and Danish) for use in populations that speak these languages. Thai. The second `subscale´ assessing prayer.. and investigators who wish to measure religiosity in greater detail may need to use a combination of measures [14]. Likewise. Conclusions The DUREL is a brief. including validation using changes in wording.. comprehensive. For those wanting more comprehensive measures of religion/spirituality. Hinduism or Buddhism). meditation and Scripture reading (NORA). Norwegian. It is a reliable measure of the three major dimensions of religiosity. has been related to poorer physical health. Other limitations of the DUREL relate to the fact that religiosity is a complex construct. more social support. Portuguese. 4.Religions 2010. and may be less accurate in its assessment of religiosity in Eastern religious traditions (e. depending on population [13]. These are reviewed elsewhere [14]. on the other hand. better physical health. Japanese. the word “church” could be replaced by “temple” or “mosque” for non-Christian samples.” Further studies in these populations are needed to confirm or refute this claim. the word “Bible” could be replaced by “Torah” or “Koran” or “writings of Buddha. Christianity. Published studies now underscore this concern. However. and lower mortality [12]. greater social support. increasing the likelihood of a positive correlation. 1 84 private religious activities like prayer are often turned to as a way of coping with the stress in response to these conditions. lower health service use. and slower progression of disability over time. especially those who want to include only a few questions on religion in their surveys and yet measure the religious domain comprehensively. Romanian. Measures of Religiosity is a good resource [15]. The DUREL has now been used in over 100 studies. easily used measure of religiosity that is designed for use in large epidemiological studies.g. The DUREL. 2. but only that the wording may need to be adapted to those specific religious traditions. and so has proven usefulness in health outcomes research. this does not necessarily mean that the DUREL is not valid in these populations.4. . and has been associated with both less and more depression. and is now being widely used around the world. Persian/Arabic. resulting in negative correlations). and there is ongoing debate about the definition and interpretation of intrinsic religiosity. The DUREL has now been translated into almost a dozen different languages (Spanish. German. Chinese. Judaism and Islam). although it is important to pay attention to the scoring and appropriate analysis of the subscales in relationship to health outcomes if results are to be meaningful. has been associated with faster remission of depression. lower rates of depression. or its subscales.g. and more and more investigators are choosing to use this index. The first `subscale´ assessing religious attendance (ORA) has been related to less depression. whereas attending religious services may serve to prevent these illnesses.

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